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There are limited data on the use of extracorporeal membrane oxygenation (ECMO) for pregnant and peripartum women with COVID-19 associated acute respiratory distress syndrome (ARDS). Pregnant women may exhibit more severe infections with COVID-19, requiring intensive care. We supported nine pregnant or peripartum women with COVID-19 ARDS with ECMO, all surviving and suffering no major complications from ECMO. Our case series demonstrates high-maternal survival rates with ECMO support in the management of COVID-19 associated severe ARDS, highlighting that these pregnant and postpartum patients should be supported with ECMO during this pandemic.

This study aimed to develop a definition of vasoplegia that reliably predicts clinical outcomes. Vasoplegia was evaluated using data from the electronic health record for each 15-minute interval for 72 hours following cardiopulmonary bypass. Standardized definitions considered clinical features (systemic vascular resistance [SVR], mean arterial pressure [MAP], cardiac index [CI], norepinephrine equivalents [NEE]), threshold strategy (criteria occurring in any versus all measurements in an interval), and duration (criteria occurring over multiple consecutive versus separated intervals). Minor vasoplegia was MAP 60 mm Hg or SVR 800 dynes⋅sec⋅cm-5 with CI 2.2 L/min/m2 and NEE ≥ 0.1 µg/kg/min. Major vasoplegia was MAP 60 mm Hg or SVR 700 dynes⋅sec⋅cm-5 with CI 2.5 L/min/m2 and NEE ≥ 0.2 µg/kg/min. The primary outcome was incidence of vasoplegia for eight definitions developed utilizing combinations of these criteria. Secondary outcomes were associations between vasoplegia definitions and three clinical outcomes: time to extubation, time to intensive care unit discharge, and nonfavorable discharge. Minor vasoplegia detected anytime within a 15-minute period (MINOR_ANY_15) predicted the highest incidence of vasoplegia (61%) and was associated with two of three clinical outcomes: 1 day delay to first extubation (95% CI: 0.2 to 2) and 7 day delay to first intensive care unit discharge (95% CI: 1 to 13). The MINOR_ANY_15 definition should be externally validated as an optimal definition of vasoplegia.

Introduction: Post-operative right ventricular failure (RV failure) is the single largest contributor to short-term mortality in patients with left ventricular assist devices (LVAD); yet predicting which patient is at risk of developing this complication in the pre-operative setting has remained beyond the abilities of experts in the field. We hypothesized that deep artificial intelligence (AI) driven characterization of subtle pre-operative myocardial motion features, could predict post-operative RV failure in LVAD patients. Methods: We developed a novel echocardiography AI system using an improved dense trajectory algorithm that tracks motion vectors in an unsupervised fashion, and a 3-dimensional convolutional neural network that tracks spatiotemporal features from videos. We used pre-operative ECHO videos from a 536 patient multicenter echocardiographic and clinical dataset, and via a standard 10-fold cross validation, trained and validated the AI system to predict severe or higher grades of post-operative RV failure at the time of index hospitalization. Finally, we independently benchmarked our AI system against clinicians equipped with contemporary clinical risk scores to predict post-operative RV failure (Penn and CRITT score) and manually derived echocardiographic metrics of RV function. Results: 173 (32%) patients were adjudicated to have severe post-operative RV failure. The area under the receiver operator characteristic curve (AUC ROC) for the AI system was 0.86 (95% CI 0.824-0.896). The performance of our AI system exceeded that of both the best performing clinical risk score and manually derived echocardiographic metric by a significant margin (ΔAUC +0.30, 95% CI 0.27 - 0.33 and ΔAUC +0.24, 95% CI 0.21 - 0.27; both p &lt 0.0001). Conclusions: A novel ECHO AI system trained and validated on a multicenter dataset outperformed clinical experts equipped with both contemporary risk scores and manually calculated echocardiographic metrics.

Background: The NuPulseCV intravascular ventricular assist system (iVAS) provides extended duration ambulatory counterpulsation via a durable pump placed through the distal subclavian artery. Methods: We performed a prospective, single-arm, multicenter, US Food and Drug Administration-approved feasibility trial of iVAS therapy as a bridge to transplant or decision following the FIH (First-In-Human) trial. Results: Forty-seven patients were enrolled, and 45 patients (median 61 years old, 37 males, and 30 listed on United Network of Organ Sharing) received iVAS support for median 44 (25–87) days. There were no intraoperative complications. Success was defined as survival or transplant on iVAS therapy free from disabling stroke. Outcome success at 30 days (the primary end point of this study) and at 6 months was 89% and 80%, respectively. During 6 months of iVAS support, 2 patients died and 2 patients experienced disabling neurological dysfunction. Six-minute walk distance, 2-minute step test, and Kansas City Cardiomyopathy Questionnaire score improved during 4-week iVAS support. Conclusions: This feasibility trial demonstrated promising short-term outcomes of iVAS therapy with improved functional capacity and quality of life during the therapy. Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02645539.

The model for end-stage liver disease (MELD) has been used as a predictor of mortality after left ventricular assist device (LVAD) placement. However, improvement or worsening of MELD and how those changes affect outcomes is unknown. We performed a retrospective analysis of 244 patients implanted with a continuous flow (CF) LVAD. Patients were dichotomized at admission into low- or high-risk categories using a cutoff of MELD ≥ 19, and they were reclassified at day of implant forming four groups: Group LL (low to low, remained low risk), LH (low to high, worsened to high risk), HH (high to high, remained high risk), and HL (high to low, improved to low risk). Patients who improved to a low risk (group HL) had the same 1 year survival as those that remained low risk (group LL; 80% vs. 77%; p = 0.6). However, patients who were initially classified as low risk and worsened to a high risk (group LH) had a survival that was worse than those that were consistently high risk (group HH; 55% vs. 10%; p = 0.01). Model for end-stage liver disease reclassification after adjusting for commonly attributed risk factors remained an independent predictor for mortality, including patients classified as Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 and 2. In conclusion, our MELD score reclassification is an independent and powerful predictor of mortality in patients undergoing LVAD implantation.

As with cancer survivors, HIV-infected people may have unique physical, psychological, social, and existential challenges over their lifespans, yet no single instrument can assess such challenges. A newly created Impact of HIV Survey, modified from Zebrack's Impact of Cancer Scale, was developed and completed by 356 HIV-infected patients on antiretroviral therapy. Factor analyses confirmed seven scales within 38 items: Health Awareness, Positive Self-Evaluation, Positive Outlook, Value of Relationships, Negative Self-Evaluation-Outlook, Health Anxiety, and Body Changes (Cronbach's alphas range = 0.54-0.93). Participants scored high on health awareness, positive outlook, and value of relationships; high on health worry; and low on body image concerns. Patients with HIV for 15 years and longer tended to have higher positive self-evaluation scores and lower negative self-evaluation-outlook scores compared to those with HIV for a shorter duration. The initial survey version had good internal validity with potential utility in research and clinical care.

Tone of voice in communication between patients and rheumatologists may offer insight into problems of treatment adherence in patients with rheumatoid arthritis.The aim of this study was to evaluate physician-patient affective vocal tone within the medical encounter and its relationship to treatment adherence in ethnically diverse patients with rheumatoid arthritis.The consultations of 174 patients with rheumatoid arthritis were audio recorded at a baseline visit. Of these, 135 completed follow-up adherence measures at 3 months. The positive and negative affective tones of patients, physicians, and interpreters (and distressed tones of patients and interpreters) were assessed using the Roter Interaction Analysis System affective communication scale. Treatment adherence was evaluated at baseline and at 3 months using the Compliance Questionnaire Rheumatology.A total of 117 baseline consultations were in English (n = 42, 36, and 39 white, African American, and Hispanic patients, respectively), 24 in Spanish, and 33 with an interpreter (total = 174). Patients reporting poorer adherence were rated as having more distressed affect and less positive affect than patients reporting greater adherence. Physicians expressed more positive affect to more educated patients. Physicians and patients reciprocated one another's positive and negative affect. Controlling for baseline adherence, physician negative affect predicted greater adherence at 3 months for Hispanic patients, regardless of language choice, compared with white patients.Patients' affective tones offer clues to problems patients may have with treatment adherence and well-being. More research is needed regarding why physicians' expression of negative affect may facilitate adherence for some groups of patients.

Objective—Variation in the utilization of total knee arthroplasty (TKA) for patients with osteoarthritis has been well documented. Conceivably, patient preferences may play a major role in these differences; however, this has not been adequately assessed. The purpose of this study was to conduct a qualitative analysis of decision-making factors influencing preferences for TKA in patients with knee osteoarthritis. Methods—We conducted six focus groups of patients with knee osteoarthritis from diverse ethnic backgrounds attending primary care clinics affiliated to the largest private outpatient institution in Houston, TX. All groups were lead by race-concordant facilitators. The group discussions were centered on factors considered to be important in the decision-making for TKA. Thematic analysis was conducted, using a grounded theory approach aided by qualitative software. Results—Several themes emerged from the groups’ discussions. Positive and negative personal experiences played a major role in decision-making. Generally, participants had good expectations about improved function and quality of life, but a number of fears were identified, the most prevalent being fear of a lengthy recovery, followed by fear of complications and of anesthesia. Additional emerging themes included trust in surgeon, financial concerns, and worries about general health. Conclusions—The attitudes and beliefs of patients with knee osteoarthritis about TKA are largely based on personal experiences, expectations, and fears, and they are largely influenced by their close social environment. These findings emphasize the need for open doctor-patient communication around individual experiences to achieve satisfactory shared decision-making for TKA. Osteoarthritis is a prevalent source of disability in elderly individuals, particularly that of the knee or the hip (1–3). There are not currently any therapies that are known to stop or reverse the progression of osteoarthritis, so treatment of the disease is largely centered around managing its symptoms. Patients with moderate-to-severe osteoarthritis who do not respond to therapy may elect to undergo elective surgery to replace the knee (total knee arthroplasty) or the hip (total hip arthroplasty). These surgeries are known to have substantial benefit to patients, proving effective in terms of alleviating pain, improving function, and improving quality of life (4–6).

A consensus meeting of representatives of 18 Latin-American and Caribbean countries gathered in Reñaca, Chile, for 2 days to identify problems and provide recommendations for the care of patients with rheumatoid arthritis (RA) in Latin America, a region where poverty and other health priorities make the efforts to provide effective and high quality care difficult. This report includes recommendations for health professionals, patients, and health authorities in Latin America, with an emphasis on education and therapeutic issues.Fifty-one rheumatologists (list available only online on the JCR website) from 18 Latin-American and Caribbean countries with a special interest in RA participated in the consensus meeting. Participants were experts identified and appointed by the National Societies of Rheumatology affiliated with the Pan-American League of Associations for Rheumatology (PANLAR) and by the Grupo Latino Americano De Estudio de Artritis Reumatoide (GLADAR)-an independent group of Latin American rheumatologist researchers were also invited to the meeting. Eight topics were identified as priorities: patient, community and allied health professional education, health policy and decision making, programs for early detection and appropriate treatment of RA, role of classic disease modifying antirheumatic drugs (DMARDs), role of biologic therapy, and drug safety surveillance. To reach consensus, a survey with questions relevant to the topic of interest was sent to all participants before the meeting. During a 2 day meeting, the answers of the survey were reviewed and discussed by each group, with final recommendations on action items.The specific topic of the survey was answered by 86% of the participants and 68% of them answered the entire survey. It was agreed that RA and rheumatic diseases which are currently not but should be public health priorities in Latin America, because of their prevalence and impact on quality of life.Strategic areas identified as priorities for our region included: early diagnosis and access to care by multidisciplinary teams, creation of databases to identify infections with the use of biologic agents in RA which are relevant to Latin America, and overall efforts to improve the care of RA patients in accordance with international standards. Implementation of educational programs aimed to improve self-management for patients with RA was also considered crucial.

Purpose of review Patient-physician communication is a vital element of the process of care. In numerous studies, communication behaviors during the medical interaction have been significantly associated with a variety of patient satisfaction and health outcomes. The purpose of this review is to synthesize recent findings in the area of patient-physician communication, particularly as they relate to patients with rheumatic disease. Recent findings Although there is scant research on the medical interaction with patients with rheumatic disease specifically, there is a large body of literature examining patient-doctor communication in other chronic diseases. Because many of the findings of studies conducted in patients with other diseases can be extended to patients with rheumatic disease, this review also covers the most salient literature published in the past year on patient-doctor communication in chronic diseases in general, in addition to covering publications in the field of rheumatology. Summary The literature reviewed shows that patients' expectations of medical encounters are not always fulfilled and that patients desire increased participation and information sharing. Establishing patient-centered care is a challenging goal, but fortunately, recent studies show that physicians can be trained, irrespective of the years in practice, to provide patient-centered care and increase patient participation and satisfaction with care.

To identify patients at high risk of functional dependence and examine the progression of disability after a hip fracture.This was a population-based prospective inception cohort study of all patients aged 65+ yr who fractured a hip between July 1996 and August 1997. Demographic, socioeconomic, social support, and health status information was assessed in the hospital and 3 mo postfracture.The analysis included 367 patients. Almost all patients with cognitive impairment were functionally dependent postfracture, with new disabilities frequently occurring in transferring. Among patients of high mental status, increased risk of functional dependence was associated with advanced age, more co-morbidities, hip pain, poor self-rated health, and previous employment in a prestigeous occupation. Bathing disability was most likely in those who functioned independently prefracture; a disability in dressing was most common otherwise.Hip pain is amenable to treatment and may improve chances of functional recovery. Patients can be assisted in regaining prefracture function if they are targeted for rehabilitation on the basis of mental status. The focus should be on bathing and dressing among patients of high cognition and transferring among those patients with mental impairment.

Background and Purpose —In light of previously reported concerns regarding carotid endarterectomy (CEA) use in our city, our goal was to determine the influence of a prospective audit and educational campaign on the performance of CEA with respect to surgical appropriateness and complication frequency. Methods —Results of our previous audit of 291 CEAs, along with CEA practice guidelines and notification of prospective surveillance, were supplied to surgeons performing CEA in our city. After this, 184 consecutive patients undergoing CEA from September 1996 to August 1997 were followed prospectively. On the basis of blinded standardized remeasurements of angiographic carotid stenoses, CEA was classified as appropriate for patients with symptomatic carotid stenoses ≥70%, uncertain for those with symptomatic stenoses Results —Forty percent of patients were asymptomatic. Compared with our prior audit, the rate of appropriate CEAs improved from 33% previously to 49% of cases in the present study ( P =0.0005), uncertain indications did not change significantly (49% versus 47%; P =0.61), and inappropriate indications dropped from 18% to 4% ( P =0.00002). Perioperative stroke or death occurred in 6.4% of symptomatic patients but developed in only 2.7% of asymptomatic patients, which was improved from the 5.1% rate previously found. Conclusions —In our city, the use of a surgical audit identified areas of concern regarding CEA, and subsequent education and ongoing surveillance significantly improved the use and performance of this procedure.

We report the case of a 50-year-old man with congestive heart failure who became a candidate for organ donation after anoxic brain injury after cardiopulmonary resuscitation (CPR) who was on a venoarterial extracorporeal membrane oxygenation (ECMO) support. On visualization, the donor's lung was acceptable for lung transplantation to a 68-year-old male patient with a chronic history of pulmonary fibrosis. Right single-lung implantation was successfully performed in the recipient. Herein, we report a case that highlights our institution's result suggesting that the use of a lung previously on ECMO support can safely and potentially expand the donor lung pool in carefully selected patients.

To report a case series of rhegmatogenous retinal detachment (RRD) after laser-assisted in situ keratomileusis (LASIK) and its incidence at a mean of 24 months.The clinical charts of patients who experienced RRD after LASIK were reviewed. Five refractive surgeons and 24,890 myopic eyes that underwent surgical correction of myopia ranging from -0.75 to -29.00 diopters (D) (mean, -6.19 D) participated in this study.Thirteen eyes from 12 patients developed RRD after LASIK. Rhegmatogenous RD occurred between 1 and 36 months (mean, 12.6 months) after LASIK. Eyes that developed RRD had from -1.50 to -16.00 D of myopia (mean, -6.96 D) before LASIK. Rhegmatogenous RD were managed with vitrectomy, cryoretinopexy, scleral buckling, argon laser retinopexy, or pneumatic retinopexy techniques. The incidence of RRD at a mean of 24 months after LASIK in this study was 0.05%.Rhegmatogenous RD after LASIK is infrequent. If managed promptly, good vision can result. No cause-effect relationship between LASIK and RD can be proved from this study, but the authors recommend that patients scheduled for refractive surgery undergo a thorough dilated indirect fundus examination with scleral depression and treatment of any retinal lesions predisposing them to the development of RRD before LASIK surgery is performed.

Etude des glandes de Meibomius par biomicroscopie transillumination et photographie infrarouge. Les resultats suggerent qu'un trouble de la fonction des glandes de Meibomius s'associerait au developpement de depots (lipides) sur les lentilles souples